HA

• Secondary HA


  • Infection
  • Mass occupying lesions (tumors, bleeds, inc CSF)
  • Non mass occupying lesions
  • Path outside of CNS
  • Head injury
  • Glaucoma
  • HTN
• MIGRAINE


  • Episodic (W)
  • Pathophysiology: neuronal dysfunction in trigeminal system → release of vasoactive neuropeptides like calcitonin gene-related peptide → neurogenic inflammation, sensitization, headache
• AURA


  Cortical spreading depression (a wave of neuronal/glial depolarization, moving slowly across the cerebral cortex), corresponds to clinical symptoms, due to serotonin (high causes vasoconstriction, decreases during attack causing vasodilation)
• Etiology/Risk factors for MIGRAINE


  • Inherited increased neuronal excitability
  • Females 30-39yo
  • Recurrent GI disturbance
  • Benign paroxysmal vertigo
  • Torticollis
• Migraine triggers


  • Emotional or physical stress
  • Lack or excess of sleep
  • Missed meals
  • Specific foods (e.g., chocolate)
  • Alcoholic beverages
  • Bright lights
  • Loud noise
  • Menstruation
  • Use of oral contraceptives
• Familial Hemiplegic Migraine (FHM)

  • Type I: CACNA1A gene mutation
  • Type II: ATP1A2 gene mutation
  • Type III: SCN1A gene mutation
• Symptoms/Signs of MIGRAINE


  • Irritability
  • Depression
  • Fatigue
  • Aura
  • Pounding/pulsating one side of head
  • Nausea/vomiting
  • Irritability
  • Pain or discomfort
  • Sensitive to light/sound/smells
  • Blurring vision
  • Osmophobia
  • Cognitive impairment
  • One sided head pain
  • Worse with routine physical activity
  • Aura symptoms before head pain
  • Visual field defects (scotoma)
  • Light flashes (photopsia)
• POUND


  Pulsatile, One day, Unilateral, Nausea/vomiting, Disabling
• Treatment for MIGRAINE


  • Rest in dark/quiet room
  • Hydrate
  • Sleep
  • Analgesics (simple/combined-excedrin)
  • Serotonin antagonists
  • Calcitonin gene-related peptide antagonists
• Treat migraine if 2-3 migraines/mo, significant disability inhibiting ADL, encourage regular sleep/meals/hydration/prophylaxis tx
• Understand treatment options for migraine, like if they have comorbidities-how to treat those along with their migraines (antiepileptic, CV, antidepressant, monoclonal antibodies against calcitonin gene related-peptide, botox helps a lot w/o significant side effects)
• Avoid opioids in migraine treatment due to risk of rebound headache
• CLUSTER HEADACHE


  • Rare (0.1%), 30yo M, smoking, periods of stress, allergic rhinitis, sexual intercourse, excessive alcohol
  • Pathophysiology: Hypothalamus involvement → episodic occurrences of cluster attacks… Posterior hypothalamic activation → secondary trigeminal stimulation → afferents travel to nucleus caudalis
• Etiology/Risk factors for CLUSTER HEADACHE


  • Unknown, but probably genetic
• Symptoms/Signs of CLUSTER HEADACHE

  • Trigeminal autonomic cephalalgias (TACs)
  • Symptoms come and go in clusters of 8-10 days with symptoms on the same side of the head like runny nose, red eye, tearing, eye lid swelling (autonomic symptoms)
  • Very strong pain that is shooting, stabbing, around an eye
  • Waken patient at the same time "alarm clock headache" lasting minutes-hours
  • Occurring in ophthalmic nerve distribution region
  • One sided sharp stabbing/burning orbital/supraorbital/temporal head pain
  • 1-8 episodes/day lasting 5 minutes-3 hours
  • Restless, agitated, suicidal ideations
• Types of CLUSTER HEADACHE

  • Episodic (daily over 6-12 weeks, with remission period up to 12 months)
  • Chronic (no substantial remission period)
• Diagnosis of CLUSTER HEADACHE requires CT/MRI to rule out cranial lesions
• Diagnostic Criteria for CLUSTER HEADACHE

  • Five unilateral/orbital/supraorbital/temporal attacks
  • 1-8 episodes daily, less than 3 hours in duration
  • Agitation/restlessness
  • At least one autonomic symptom on same side as headache
• Treatment for CLUSTER HEADACHE

  • Oxygen
  • Sumatriptan/zolmitriptan
  • If above doesn't help: intranasal lidocaine, oral ergotamine, IV dihydroergotamine
  • Surgery of greater occipital nerve and others as last ditch efforts
  • Deep brain stimulation is an option for all headaches
• Prophylaxis for CLUSTER HEADACHE

  • Verapamil
  • Glucocorticoids
  • Lithium
• TENSION HEADACHE


  • Very common (1.4 billion Americans annually)
  • Pathophysiology: Myofascial trigger points in the pericranial musculature may be cause → Trigger points activate vasculature surrounding nociceptors causing episodic tension headaches → Prolonged nociceptor stimulation can lead to pain pathway sensitization with hyperalgesia leading to chronic tension headache
• Etiology/Risk factors for TENSION HEADACHE


  • Stress
  • Lack of sleep or dehydration
  • Genetic/environmental factors
• Symptoms/Signs of TENSION HEADACHE


  • Feel like a band squeezing down with constant pressure
  • Mild/moderate pain, lasts for a few hours
  • Pulsating head pain that doesn't worsen with activity
  • Photophobia/phonophobia
• Types of TENSION HEADACHE

  • Episodic: rare (less than 1/month), common (less than 14 headaches/month)
  • Chronic: more than 15 headaches/month
• Physical Exam findings in TENSION HEADACHE


  Increased muscle tension in head, neck and shoulder
• Diagnostic Criteria for TENSION HEADACHE


  • No nausea/vomiting, only light/sound sensitivity
  • 2 or more of the following: both sides of head, non-throbbing, moderate intensity, not worse during physical activity
• Treatment for TENSION HEADACHE

  • Analgesics
  • Caffeine
  • Butalbital

  Chronic: Antidepressants/anticonvulsants, therapy to identify triggers of stress
• Concussion/Traumatic Brain Injury


  Trauma to patient's head where the brain gets jostled against intracranial surfaces "coup contrecoup" injury
• Concussion/Traumatic Brain Injury Pathophysiology

  Axon stretch causes injury→Depolarization/AP causes neurotransmitter release → K efflux → Inc membrane pumping → Hyperglycolysis → Lactate accumulation→ Ca influx/sequestration/mitochondrial dysfunction→Oxidative phosphorylation →Enzyme activation/Initiation of apoptosis
• Concussion/Traumatic Brain Injury


  • Changes in glucose metabolism, Dec cerebral flow, Mitochondrial dysfunction
• Mild Concussion/Traumatic Brain Injury

  GCS 13-15 30min post injury, LOC <30min, Post trauma amnesia <24hr
• Symptoms of Concussion/Traumatic Brain Injury

  • Irritable, Mood changes, Confused/Disoriented, Amnesia, Foggy, Cannot concentrate, Headache, Dizzy, Hard time balancing, Visual changes, Drowsy, Sleeping more or less, Can't fall asleep